Healthcare Provider Details

I. General information

NPI: 1023481470
Provider Name (Legal Business Name): NICHOLAS LARICCHIA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2015
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 S KENSINGTON DR
APPLETON WI
54915-4136
US

IV. Provider business mailing address

1800 S KENSINGTON DR
APPLETON WI
54915-4136
US

V. Phone/Fax

Practice location:
  • Phone: 920-749-9775
  • Fax:
Mailing address:
  • Phone: 920-749-9775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.299181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: